Oral Contraception

Do you have any recent or past medical history of note?
If yes, please provide details

Yes

No

Do you take any current or repeat medicines?
If yes, please provide details

Yes

No

Are you over 35 years of age and a smoker?

Yes

No

Do you have a family history of blood clots or thrombosis?
If yes, please provide details

Yes

No

Have you been taking your current contraceptive pill for more than a year?

Yes

No

Have you had a check up with your doctor / nurse about your contraceptive pill in the last year?
If yes, please provide details

Yes

No

Is the contraceptive for your own use?

Yes

No

Women only: Are you pregnant or is there a possibility you may be pregnant?

Yes

No

Are you overweight? Or have blood pressure problems?
If yes, please provide details below (if you are unsure, the pharmacist can check this for you)

Yes

No

Do you have any of the following conditions? Diabetes, migraine headaches, cancer, HIV, high blood pressure, liver disease?
If yes, please provide details

Yes

No

Have you been prescribed the same contraceptive pill for more than 9 months?

Yes

No

Are you having any problems with your current contraceptive pill such as irregular bleeding / periods?
If yes, please provide details

Yes

No

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